Background Information

Site

Has there been any recent major clinical redevelopments / refurbishments?

Provide details

Cleaning / Disinfectant

What is the principal cleaning / disinfectant used?

Provide brand and product details

How frequently are the high touch items cleaned?

How frequently are the high touch items cleaned?

Provide additional details, type, where the technology is used and frequency of use?

How frequently are the high touch items cleaned?

Has there been any Identified safety or equipment related issues associated with your cleaning solution?

Do use any other cleaning disinfectant wipe / solutions ?

Please list additional products and how are they used?

Where is the wipe used?

What is the frequency of use?

Maintenance

Health Service Contact: Maintenance

Title

Contact Telephone

Email:

Support Services

Health Service: Support Services (Cleaning)

Title:

Contact Telephone:

Email:

Medical Devices

Health Services: Clinical Engineering (Biomedical)

Title

Contact Telephone:

Email:

Clinical Services

Health Services: Senior Clinical Representative

Title

Contact Telephone:

Email:

Department (1)

Department:

Have any medical devices or Infrastructure been identified as showing environmental stress cracking?

ESC may be:
• Brittle cracking with no indication of yielding or indentation.
• Fine hairline cracks.
• Multiple initiation points.
• Repeated cracking in the same item.

ESC

What category of equipment?

Provide select category of equipment?

Provide brand and model no:

Add photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Provide details

Provide brand and model no:

Add Photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Department (2)

Department:

Have any medical devices or Infrastructure been identified as showing environmental stress cracking?

ESC may be:
• Brittle cracking with no indication of yielding or indentation.
• Fine hairline cracks.
• Multiple initiation points.
• Repeated cracking in the same item.

ESC

What category of equipment?

Provide select category of equipment?

Provide brand and model no:

Add photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Provide details

Provide brand and model no:

Add Photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Department (3)

Department:

Have any medical devices or Infrastructure been identified as showing environmental stress cracking?

ESC may be:
• Brittle cracking with no indication of yielding or indentation.
• Fine hairline cracks.
• Multiple initiation points.
• Repeated cracking in the same item.

ESC

What category of equipment?

Provide select category of equipment?

Provide brand and model no:

Add photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Provide details

Provide brand and model no:

Add Photos

Extent of cracking per each individual item classified as:
0 – No cracking
1 – Minor (1 or 2 small cracks)
2 – Major (multiple cracking)
3 – Severe (extensive cracking and resulting material loss and damage

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.